Hypospadias - parent information

What is hypospadias?

Hypospadias means that the hole (‘meatus’) through which your son passes urine is not at the tip of the penis as it should be. Hypospadias occurs during development before birth and affects approximately three per 1000 births. Hypospadias can be corrected by surgery.

What surgery will be needed?

There are many different operations for hypospadias and the one performed will depend on how far down the shaft of the penis the opening is, however each has common elements.

Your son will require a general anaesthetic and sometimes a local anaesthetic or an injection into the lower back is also given to make his penis numb. Any bend in the penis must be straightened. For severe hypospadias a graft is placed underneath the penis to allow for a second operation at least six months later. In more straightforward cases (85%) the urethra (the hole that urine passes through) is moved to the tip. Sometimes the foreskin is then reconstructed but where the foreskin is not reconstructed the penis will have the appearance of being circumcised at the end of the operation. Your surgeon will discuss which type of operation your son is likely to need and also whether your son’s foreskin is likely to be reconstructed or not however, sometimes, due to findings once your son is under anaesthetic and in the operating room, a different type of repair and / or use of the foreskin may be felt to be in your son’s best interests. The length of the operation itself will be between one and three hours depending on which procedure is required.

Depending on the type of hypospadias surgery your son has, a catheter (often called a ‘stent’) may be left in place for five to ten days. A stent is usually left in place because surgery involves creating a ‘new’ urethra (tube which your son passes urine) and this needs time to heal without being contaminated with urine. Your surgeon will also place a dressing around the penis (for a period of 5-10 days).

Before admission to hospital

Preoperative assessment

You will be asked to complete a ‘health screening questionnaire’ when your child is added to the waiting list; this will usually be completed with you by our pre assessment team over the telephone.

Blood tests are not required unless your child has a known bleeding disorder or, if such a disorder affects a close family member.

Purchasing suitable painkillers

It is essential that you purchase some children’s pain killers such as Paracetamol (e.g. Calpol) and Ibuprofen before admission to hospital so that you have these available at home after discharge. If it is likely that your son will need ‘stronger’ pain killers, these will be supplied via the hospital.

If your child becomes unwell

If your child has a cold, cough, coronavirus (Covid) or illness such as chicken pox the operation will need to be postponed to avoid complications. Please telephone us (the telephone number is provided at the end of this leaflet) to discuss, prior to coming to hospital.

Starvation times

Your son will not be able to eat and drink before the operation. Specific advice about this will be given on your booking confirmation letter.

Admission to hospital

Hypospadias surgery usually takes place when the child is aged between 12 and 18 months of age.

You will be asked to bring your son to one of our children’s wards, usually early in the morning on the day of surgery. When you arrive you will be seen by the nursing staff plus a doctor and an anaesthetist.

A parent will be able to accompany your son when he goes to the anaesthetic room to go to sleep for his operation and also be present in the recovery area when he wakes.

What happens after the operation?

Most children start to drink and eat as soon as they are fully awake. Once fully awake, your son will be moved back to the ward. You will be taught how to look after your son at home by the nurses and nurse specialist. Most boys who have undergone a single stage hypospadias repair will then be discharged on the evening on the same day as their operation but boys who have undergone the first of a two stage operation will require an overnight stay. If your son needs to stay in hospital overnight a bed will be provided for a parent to stay.

Looking after your son at home

Your nurses and nurse specialist will teach you how to look after your son at home. The following describes care required.

Your son will need to return to the ward to have the stent removed by a member of the paediatric surgery nurse specialist team between five and ten days after surgery. This will be organised with you before discharge.

Types of stent

Foley catheter used as a ‘dripping stent’

A Foley catheter is held in place with an internal balloon placed within the bladder and an external suture (stitch).

Boys with a Foley catheter usually wear two nappies (called the ‘double nappy technique’). The inner most nappy has a small circular hole cut into it. The catheter passes through this hole so that the urine drips into the outer most nappy and hence keeps the urine away from the wound itself. (See section on ‘double nappy technique).

On removal of the catheter the suture is removed then the balloon is deflated and then the catheter gently removed.

Stent with urine bag

For boys who are too old to wear nappies a stent will be used which can have a catheter bag attached to it. In the day time the urine collection bag can be attached with Velcro straps to your son’s leg so he can mobilise but overnight a ‘night bag’ is also attached because your son may produce more urine over night than the day bag can hold. (See section on caring for leg and night bags).

Suprapubic catheter

Occasionally it is necessary for a boy to have a suprapubic catheter in addition to a stent. A suprapubic catheter is a flexible tube that is passed through the abdominal wall (skin and muscle layers) via a small cut below the belly button, directly into the bladder. It is designed to drain urine directly from the bladder out into a bag rather than via the penis and is used in boys who have more extensive surgery. The suprapubic catheter drains the urine into a bag which can be worn on your son’s leg during the day time but overnight a ‘night bag’ is also attached because your son may produce more urine overnight than the day bag can hold. (See section on caring for leg and night bags).

Double nappy technique

The double nappy technique is used for boys who have a stent and wear nappies (see above).

Equipment needed:

• Two nappies of an appropriate size
• Sharp pair of scissors
• Suitable tape as provided

Procedure:

• Take a nappy from the packet and before unfolding it, mark the centre.
• Draw a cross (+) shape approximately 3 cms in length and width at this point.
• With a sharp pair of scissors, cut along this line. This makes four triangle shapes.
• Cut eight strips of tape approximately 1.5 cms wide and 8 cms long.
• Fold one of the triangle shapes into the nappy. Hold it in place with a piece of the tape.
• Repeat until all four of the triangle shapes have been taped down.
• Now stick a strip of tape between the four already stuck down. This will ensure there is a complete circle of tape. (If there is not a complete circle of tape, add more tape because this will prevent the gel beads contained within the nappy from falling out and causing irritation to the wound).
• Lay your son on the nappy with the hole at the front.
• Carefully position the tip of the stent so that it passes through the hole in the nappy.
• Use the Velcro tabs on the nappy as normal to hold the nappy in place.
• Lay your son on the second nappy (without a hole) and do this up as you do with a normal nappy over the stent. It is important to ensure that the stent does not get too bent or else it will not be able to drain urine properly.
• The inner nappy should be changed daily / with each bowel motion (‘poo’) being passed. The outer nappy should be changed regularly as it should be as wet as normal nappies.

Sometimes the child’s young age and size results in the catheter being of sufficient length that it can be passed around the side of the inner nappy and drip urine into the outer one and thus cutting a hole in the inner one is not necessary. This will be carefully judged by the consultant and nurse specialist prior to your child’s discharge to prevent dripping stent related complications.

Caring for leg and night bags (for child who does not wear nappies)

Leg bags

• Urine should run consistently into the leg bag and it should be emptied every two hours. Your nurse will show you how to empty the catheter bag. To prevent infection it is important to wash your hands before and after emptying the bag and to dry the tap through which the urine is emptied on a piece of toilet tissue.
• The leg bag should be securely attached to your child’s leg using the Velcro strapping provided. Usually one strap is kept just above the knee and the other below. It is very important that the catheter bag is securely strapped to prevent the catheter bag ‘dragging down’ which will pull on the penis.
• The leg bag should not become detached from the catheter (‘stent’) itself. However, should this happen, a new leg bag should be applied and a spare will be provided for your use.

Night bags

• Overnight your son may produce more urine than the leg bag will hold and therefore another, larger, bag (called a ‘night bag’) will need to be used.
• The night bag should be attached onto the emptying port of the leg bag when your son goes to bed and disconnected again in the morning. Your nurse will show you how to do this.

Important points to remember are:

1. Wash your hands before connecting the night bag.
2. Remove the protective cover from the night bag and, without touching the tip of the night bag, push it into the flexible plastic emptying port of the leg bag.
3. Open the tap on the leg bag to allow urine to then drain through the leg bag and into the night bag.
4. In the morning, wash your hands and then close the tap on the leg bag.
5. Carefully pull the night bag out of the flexible plastic emptying port of the leg bag, being careful not to remove this flexible port from the leg bag itself.
6. Use a piece of toilet tissue to ensure the emptying port on the leg bag is dry.
7. Take the night bag to your toilet and empty the urine down the toilet. Once the night bag is empty it can be disposed of in your household bin.
8. Use a clean night bag every night to prevent infection.

Medicines for the child with a catheter (also known as ‘dripping stent’)

Your child will be given a number of different medicines to take home and it is important that these are given. Your nurse will discuss these with you and it is important to read the instructions on the bottle carefully. You may also find the table at the back of this leaflet useful to help you.

• Antibiotics: To prevent infection. These should be given regularly
• ‘Pain killers’: These should be given regularly to prevent pain.
• Oxybutynin: Medication to help stop bladder spasm. Bladder spasm occurs when the catheter moves inside the bladder and touches the bladder wall. Some boys are troubled by bladder spasm more than others and so you will only need to give this medicine if your son is experiencing bladder spasm. Symptoms include intermittent, short lasting episodes of distress and upset.
• Laxatives: It is important to ensure your child does not become constipated whilst the hypospadias repair is healing / stent (if used) is in place. Laxatives may be prescribed by your doctor.

Restrictions on activities for the child with a catheter (‘stent’)

• It is important to keep the dressing dry until the day of removal. If ‘poo’ should get onto the dressing, merely wipe it from the dressing with baby wipes.
• Whilst the catheter (‘stent’) is in place and for six weeks after it is removed, your son should be prevented from participating in any physical activities such as climbing, PE or sport and must not sit astride items such as bicycles or toys such as rocking horses. This is to prevent the penis being accidentally knocked which can result in bleeding of the wound and / or damage to the repair.

Removal of catheters / stents

You will be given an appointment to return to the ward for your son to have his catheter (‘stent’) removed. How long after the operation this takes place depends on the type of hypospadias repair that your son had but is usually between five and ten days.

In most cases, catheters (‘stents’) are removed whilst your son is awake on our children’s day ward by a trained nurse with expertise in this area. You should give your son his pain killing medication before you leave home but no oxybutynin.

On your arrival, one of the nurses will remove the dressing and then cut any stitch present which keeps the catheter (‘stent’) in place. The retaining balloon is then deflated (by inserting a syringe in an external part of the catheter) and the tube is then gently pulled out. This takes only a minute or two but your son will need to lie still whilst this happens so another nurse or nursing assistant may lay an arm gently over your son’s legs to aid safe removal of suture and avoid any injury due to your child. Distraction with toys / books can also help to encourage your son to lay still.

Once the catheter (‘stent’) has been removed your son will need to stay in the hospital until he has passed urine. This may take a few hours and you should encourage your son to drink plenty to help this. It is usually not painful to actually pass urine after the catheter has been removed but it may feel strange for your son to have the sensation of needing to pass urine again after catheter removal and this can upset young boys.

Sometimes older children benefit from receiving medication in the form of oral sedation before catheter removal. This will be discussed with you by your nurse specialist and Consultant.

Care after catheter (’stent’) removal

• Your son can bath once the catheter (‘stent’) is removed but bubble bath should not be used for a few weeks as this can cause a ‘stinging sensation’ at the wound.
• Pain killing medicines may be needed but no longer on a regular basis. The Oxybutynin medications will no longer be required as the catheter which caused the bladder spasm has been removed.
• Your nurse will advise you regarding any antibiotic treatment your son was receiving.
• Use of topical antibiotic treatment (‘Chloramphenicol’) is often recommended; this will be discussed with you by the nurse specialist team.
• Your son must continue to refrain from activities where he is sitting astride something (for example, bikes / rocking horses etc) and physical activities such as climbing / sport until all the swelling and bruising has settled. This may take six to eight weeks. This is important because such activities can prevent the wound from healing appropriately, lead to bleeding or damage the hypospadias repair.
• Your son’s urinary stream may ‘spray’ or be passed in an altered direction initially (for example, to one side). This is due to the swelling and should have settled by the time your son is reviewed in the outpatient department.

What are the benefits related to hypospadias surgery?

Surgery is undertaken to both give the penis a more normal appearance and to allow the boy to pass urine in a standing position when he is older.

What are the complications / risks related to hypospadias surgery?

Complications are not common but include:

• Bleeding

A small amount of bleeding is not unusual but if further bleeding occurs, intervention may be required (for example, further observation on the ward, use of an additional layer of dressing or further surgery).

• Infection

Where infection occurs this will need to be treated with further antibiotics. Infection can lead to the hypospadias repair not healing properly (‘breaking down’) and thus further surgery being required.

• Hypospadias Fistula

A hypospadias fistula is a tiny hole that appears after the operation where the repair has been carried out. This will require a further, although usually much smaller, operation to correct it.

• Meatal stenosis

Meatal stenosis is a narrowing along the inside of the penis which results in urine being passed with a narrow stream and therefore under increased pressure. Meatal stenosis can occur within a few months or some years after the initial surgery to correct the hypospadias and will require intervention to correct it.

Follow up

Your son will be followed up in the outpatient department. The first appointment will take place approximately three to four months after surgery. By this time the healing process will have completed sufficiently for the surgeon to be able to advise as to whether any further surgery is likely to be needed in the future.

Chaperoning

During your child’s hospital visits he will need to be examined to help diagnose and to plan care. Examination, which may take place before, during and after treatment, is performed by trained members of staff and will always be explained to you beforehand. A chaperone is a separate member of staff who is present during the examination. The role of the chaperone is to provide practical assistance with the examination and to provide support to the child, family member / carer and to the person examining.

If you have any queries or need further information

Contact your nurse specialist:
01223 586973 (Mon to Fri 08:00 to 18:00)

Outside the above working hours including weekends and public holidays.

The ward your son was on (if the nursing staff are unable to answer your query they will liaise with the Paediatric Surgery Registrar on call)

Please note, if you have any queries / problems it is important to seek advice from the team at Addenbrooke’s Hospital as we will know about the hypospadias surgery your child has had.